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^hlffirhjzfe Aisurance Company 
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LIBRARY OF CONGRESS. 



Chap._______ Copyright No. 

SheIf.M_IP^ 



UNITED STATES OF AMERICA. 



Practical Suggestions 



to the 



cMedical Examiners 



of the 
V 



New -York Life Ins. Co. 



Copyright, iSgg, by the 

NEW-YORK LIFE INSURANCE COMPANY, 

346 6° 348 Broadway, New York. 

L. 



1029. July, '99. 




H 



41436 
SPECIAL NOTICE 



IT sometimes happens that the Applicant or the 
Examiner wishes to have facts of a peculiarly 

delicate or confidential character omitted from 
the report, and brought to the attention of the 
Medical Board alone. In these rare cases, the 
Examiner may omit them from his report, provid- 
ed he sends them under confidential cover to the 
Company, giving the name, date of birth, occupation 
and residence of the applicant. 

This information must be mailed at once, so 
that it will reach the Home Office in advance of 
the regular papers in the case. The Examiner is 
held strictly to account for any failure to comply 
with this requirement. Blank forms are furnished 
by the Company for the convenience of the Exam- 
iner in such cases. 

It is not necessary that the Examiner shall disclose 
to any one the result of bis examination. 



•ec: 



*vn«-> «^nv 







To the Medical Examiners of the New-York 
Life Insurance Company. 



It has heretofore been the custom among the Ameri- 
can Life Companies, to refuse insurance to all persons 
presenting any marked impairment either of physical 
condition or family history. From 10% to 15% of all 
applicants for insurance have thus been denied its 
benefits. For several years this Company has been 
perfecting a plan for insuring these sub-standard lives, 
and during the last three years has been gradually 
extending the practical application of this plan, until 
now it undertakes to grant to every reasonably healthy 
life a form of policy so adjusted as to treat the appli- 
cant fairly, and at the same time with perfect safety 
to the policy-holders of the Company. 

In taking this step the Company has in no way 
departed from its former conservative attitude in the 
selection of risks ; for in order that an applicant may 
obtain one of our standard policies, he must still possess 
the same degree of physical excellence as was formerly 
required. The Company separates its standard from 
its sub-standard business with the same care that it 
formerly exercised when it refused insurance to the 
latter class, and has made this radical change with a 
view simply to extending the benefits of insurance, not 
only to normal lives, but also to that large number of 
sub-standard lives which heretofore have been denied 
insurance. 



From this it will be seen that the Company no 
longer expects a Medical Examiner to recommend the 
acceptance or rejection of a risk. Aided by his special 
training in the practice of his profession, the Examiner 
collects and records the facts upon which is based the 
valuation of the risk for insurance. He is relieved of 
the embarrassment of rejecting a sub-standard risk, but 
is responsible for the accuracy and completeness with 
which the records of the personal history and physical 
condition are laid before the Company. The Company 
assumes the responsibility of treating the risk justly, 
while the Examiner must assume the responsibility of 
submitting to it all the facts. 



LIFE INSURANCE.— THE APPLICANT. 

The business of Life Insurance is based on the fact 
that, while the longevity of a single individual is uncer- 
tain, there is a fixed law, determining, within narrow 
limits, the average age at death of large numbers of 
individuals of the same age ; and that, under this law, 
it may be expected that any man in sound health, of 
temperate habits, with a good family history, and a 
healthful occupation, will live as long as the average of 
those of the same age, /. e. t will live out his " Expecta- 
tion of Life." 

In the same way among the impaired lives, whatever 
be the character or degree of the impairment, there will 
be the same uncertainty about the duration of the indi- 
vidual life, and the same certainty among large groups 
of lives of the same kind and degree of impairment. 

Involving, as it does, the purely medical questions of 
the past and present health, the family history, the 

4 



habits, hygienic surroundings and occupation of the 
individual, the business of Life Insurance requires for 
its successful prosecution the assistance of those whose 
lives are spent in the study of such questions — Medical 
Practitioners ; and because of the large sums of money 
involved, and the dangers of fraud, it is necessary that 
the Medical Examiners of a life insurance company 
should possess, besides a good medical knowledge, the 
most upright character and the soundest judgment. 

One of the most important factors in the success of a 
life insurance company, is the maintenance of a high 
standard in the selection of its risks. This is possible 
only where the Examiners in the field exercise diligence 
to discover and lay before the Company all the facts in 
each case, and where the Home Office by rigid separa- 
tion of the standard from the sub-standard lives, assesses 
each life according to its true valuation. 

With regard to most of the factors which make up a 
risk, such as physical condition, habits, medical history 
and occupation, the Medical Examiners are able to fully 
inform themselves. As to the question of build of an 
individual, this so rarely presents itself to the Examiner 
for consideration, that we give on pages IS and 16 tables 
of heights and weights, which will be found convenient 
for reference. 



MEDICAL EXAMINERS. 

Medical Examiners are selected solely for their moral 
and professional standing in the communities in which 
they reside. They hold their appointments direct from 
the Company, and retain their positions as long as their 
services prove satisfactory to it. 

5 



They are the trusted advisers of the Company, and 
their relations with the Medical Department are personal 
and confidential. It is their duty to examine applicants 
for insurance, and to furnish on the blanks provided for 
that purpose a full and complete report of the physical 
condition, of the family and personal histories, and 
any other facts that have any bearing upon the value of 
the risk. For such examinations they receive the fixed 
fee of the Company, and this fee is paid whether the risk 
is insured by the Company or not. The fees are paid 
by the Company, and not by the applicants or agents, 
and Examiners are not dependent for their appointment, 
dismissal or fees, upon either applicants or agents. 

They are not required to insure their lives in the 
Company, or to actively interest themselves in canvass- 
ing others for insurance. Indeed, they will do well to 
avoid identifying themselves with the business of Life 
Insurance, excepting in their professional capacity. 
Medical Examiners, however, cannot expect to retain 
their positions if they show any opposition to insurance, 
and especially to insurance in this Company. 

It is to the interest of all concerned that the rela- 
tions of the Examiner towards both applicants and agents 
should be cordial and friendly. To the applicants his 
position should be of the same delicate and confidential 
nature as that shown to patients who entrust themselves 
to his professional care ; and, while it is often the duty 
of the Medical Examiner to lay before the Company facts 
which the applicant or the agent wishes to conceal, yet, 
by the exercise of tact and judgment, and especially by 
firmness in his convictions, he should be able to avoid 
serious friction, and thereby maintain that harmony so 
essential to a pleasant intercourse and to satisfactory 
business results. 



He should always bear in mind that the agent's 
income depends on his ability to secure new business 
for the Company, and that he naturally looks to the 
Medical Examiner for reasonable co-operation, that he 
may secure the fruits of his labor. 

To the agent belongs the task of securing new business 
for the Company, and to the Examiner that of making 
so critical a study of these risks, and of reporting the 
results with such care, as to enable the Company to 
grant to each applicant the form of insurance to which 
the facts in his case entitle him. 

The Medical Examiner should have constantly in 
mind two important differences in mental attitude be- 
tween the patient and the applicant for insurance. In 
the first place many, especially at their first examination 
or among the younger applicants, are extremely nervous ; 
the idea that the examination may reveal some hidden 
ailment so takes possession of their minds as to disturb 
considerably the nervous equilibrium — to induce, as it 
were, a mild degree of shock. In such cases the pulse 
may be found extremely rapid or intermittent ; there is 
apt to be pallor or muscular tremor. The picture is one 
of nervous debility or of a want of normal bodily vigor. 
Whenever an Examiner meets with this condition he 
should be able, by tactful handling, to re-assure the 
applicant, and to re-establish the normal nervous bal- 
ance ; at any rate, he should make due allowance in his 
report for the disturbed mental state of his subject. 

As to the other difference to which we have re- 
ferred, when he consults his physician the patient 
endeavors to describe every detail of the disease of 
which he complains. He conceals nothing. His mental 
attitude is one of unreserved co-operation. When he is 

7 



a candidate for life insurance, the case is very different ; 
his memory for details is less acute ; his state of mind is 
one of antagonism. He believes himself to be a good 
risk, and his bias of mind in that direction is so strong 
as — no doubt, unconsciously — to color his entire history. 
On this account a medical history for life insurance is a 
very different matter from that which is obtained from a 
patient. The patient assists his physician — the applicant 
for insurance does not assist the Examiner. It requires 
time for any physician to adjust himself to this differ- 
ence in mental attitude. The skilled Medical Examiner 
has learned this lesson. 

It is on this account particularly that the Examiner 
for life insurance must bring to his task complete inde- 
pendence of character, absolute integrity, and the ability 
to detect attempts at fraud. He must constantly bear 
in mind that he is the guardian of the interests of the 
Company, and that upon his vigilance, judgment and 
integrity depends, largely, its success or failure. 



MEDICAL EXAMINATIONS. 

The object of the medical examination of an appli- 
cant for life insurance is to secure such information in 
regard to the family history and the past and present 
health of the applicant as will enable the Medical 
Board at the Home Office to place a correct insurance 
valuation on the life. 

This is best secured by following a general routine, 
to be varied as the experience of the Examiner or the 
special circumstances in any individual case may indi- 
cate. We therefore call your attention to the subjoined 



RULES AND INSTRUCTIONS FOR THE GUIDANCE 
OF MEDICAL EXAMINERS. 

Pensions. Whenever you examine a pensioner, you 
should endeavor to secure the fullest possible informa- 
tion regarding the grounds upon which the pension was 
granted, and their bearing on the longevity. The fact 
that a person draws a pension is prima facie evidence 
that he is an impaired or hazardous risk. 

Promptness in keeping appointments and in making 
examinations must be strictly observed, as any delay 
may cause a loss to the Company, to the agent or the 
applicant, for which you will be held responsible. 

Competition in Life Insurance is so acute that, while 
we wish the examinations to be made at your office 
whenever possible, we cannot insist upon having the 
applicants brought to you, but are obliged to ask you to 
make examinations at any suitable place within reason- 
able distance and at any reasonable hour. 

Privacy. We must also insist that examinations be 
made in a place free from noise and strictly in private, 
the agent or any third person not being permitted to be 
present. 

Self -written. Both the answers of the applicant 
and your report must be made out entirely in your own 
handwriting ; and where corrections are made, you 
should indicate that they are made by yourself, by 
adding your initials ; but you are not to fill in any part 
of the application blank itself. 

Relationship and Pecuniary Interest. If you are 
related to either applicant or agent, or if you have a 
pecuniary interest in the proposed insurance, you must 
refuse to make the examination, and should refer the 
agent to some neighboring Examiner. 

9 



ANSWERS MADE TO THE MEDICAL EXAMINER. 

When an applicant appears before you for examina- 
tion, you should take him into your private office or into 
a quiet room, provided for that purpose, where you 
should begin the examination by reviewing in detail the 
statements made in the application as to the full name, 
the date of birth, occupation, etc., of the applicant, and 
satisfy yourself as to his identity, and that the applica- 
tion is correctly filled out and properly signed. 

The Company requires that applications be filled out 
and placed in your hands before the examination, and 
you should consent to waive this rule only where some 
urgent reason is apparent. The Company cannot be 
held responsible for the medical fees in cases examined 
without a signed application. 

Occupation. This question should develop fully 
whether the applicant is engaged, or is likely to en- 
gage, in an occupation involving unusual hazard, or 
confinement to dusty, ill-ventilated rooms, or cramped 
or unhealthy postures, exposure to sudden variations of 
temperature, etc., or whether he is, or has been, engaged 
in the manufacture, sale or personal handling of alco- 
holic liquors. 

Habits. This question is of so great importance, 
that we are obliged to take the position that an Exam- 
iner fails to do his full duty who does not place us in 
possession of all unfavorable information which may be 
reasonably accessible to him. If personally acquainted 
with the applicant, you should be able to give all the 
facts ; if not acquainted, and you have reason to suspect 
excess, you should not depend upon his statements, but 
should secure further information through mutual ac- 
quaintances. In suspicious cases you should also be 

10 



particular to inquire if the applicant has ever resorted 
to the so-called "Gold Cure" or other treatment; if 
so, the date and result of such treatment should be 
given. This Company grants sub-standard insurance, 
adjusted to meet the degree of impairment, to persons 
who use alcohol to excess, but it has reason to know- 
that even occasional or slight excesses in its use 
markedly impair the value of a risk. We consider the 
habitual use of Opium, Chloral, Cocaine and the like, 
as much more serious even than intemperance in the use 
of alcohol, and you should investigate such cases with 
the greatest care. 

Female Risks. Women are less desirable risks than 
men, probably because in the majority of cases they 
are less carefully examined. The reasons for this are 
apparent, but should not deter the Examiner from making 
thorough, complete examination. Pregnant women, un- 
der the rule of the Company, are not accepted during 
the period of pregnancy. 

In the examination of women you should insist upon 
the removal of corsets and any other articles of clothing 
which interfere with a careful physical examination. 
We are satisfied that examinations of female applicants 
are too superficial. 

Personal Record. You should secure a complete 
statement of each of the important diseases from which 
the applicant has suffered, with a view to determining 
not only its effect upon the constitution of the applicant, 
but also its liability to recur. 

Write clearly the name of each disease, the number 
of attacks, the date and duration of each, its severity, 
and results, if any. 

All answers should be complete, but as concise as pos- 
sible. The aim should be to give the facts, but avoid 

11 



trivial details. Certain diseases, very important from 
a life insurance standpoint, often fail for some reason 
to receive satisfactory description. They are as follows : 

Asthma. State cause (if possible) , when first at- 
tacked, the frequency and severity of the seizures, and 
the date of the last attack. The Examiner should dis- 
tinguish between true Asthma and Hay Fever. The 
frequency with which Asthma occurs as a symptom of 
other diseases should also be remembered. 

Blood Spitting. No medical question in the entire 
range of our business requires the exercise on the part 
of the Examiner of greater care in securing a detailed 
answer, and no question is more frequently answered im- 
perfectly. It is only after a careful study that we are 
able to distinguish accurately between attacks which may 
be safely disregarded and those which constitute de- 
cided impairment. You should, therefore, differentiate 
between true Haemoptysis and the blood-stained sputum 
of Pneumonia, or of severe Bronchitis, or a Hemorrhage 
of the nose or throat. In all cases the cause, the 
number of attacks and the extent of each Hemorrhage 
should be recorded. 

Dyspepsia. This question is very often misunder- 
stood and imperfectly answered. We do not wish to 
know if the applicant has suffered from an indigestion 
due to over-eating at some time or other, but we do wish 
to know if he has suffered from any marked functional 
disorder, or from organic disease of the digestive organs. 
If so, a detailed history, and your opinion as to its bear- 
ings on his longevity, are required. 

Rheumatism and Gout. Repeated attacks are of 
much greater significance than a single attack. Be 
particular, therefore, to give the number of attacks and 

12 



the date of each, indicate whether severe or not, or 
accompanied by any serious complication. It is neces- 
sary also to distinguish between Articular and the 
r,o-called Muscular Rheumatism. 

Syphilis. Never refer to Chancroid as Syphilis. 
Have in mind that one is simply a local, and the other a 
constitutional, disease. Give the date and character of 
the primary lesion; the character and duration of the 
secondary or tertiary lesions ; the treatment employed, 
and when it was finally discontinued. 

This Company's experience with insured syphilitics 
has been quite unfavorable. They are decidedly sub- 
standard lives, and consequently require to be studied with 
extra care. The Company makes use of a special blank 
on which to record the detailed history of these cases. 

Medical Treatment. Ascertain from the applicant 
whether he has found it necessary to consult a physician 
for any ailment, and if so, give the name and address 
of the physician, the nature of the ailment, and the date 
of treatment. 

Family Record. If the applicant describes the 
health of living relatives as "fair," or "poor," find out 
in what respects they are not in good health. Where the 
cause of death is said to have been "change of life," 
or "childbirth," or "exposure," or where any such 
indefinite term is used, satisfy yourself as to the exact 
facts, and record them as concisely as possible. 

Where the final illness of any member of the family 
has been a protracted one, you should determine whether 
death was due to tubercular disease. Indeed, the im- 
portance of the cause of death in connection with family 
history lies principally in the direction of measuring the 
extent of the liability to Tuberculosis. 

13 



Signature. If the applicant's signature is tremulous, 
you should ascertain and record the reason therefor. 
Be careful to distinguish between the irregular, jerky 
signature of one who is unaccustomed to the use of the 
pen, and the uniformly tremulous signature of a subject 
of functional or organic disease of the nervous system. 

Amount of Insurance. If the amount of insurance 
applied for seems to you to be out of proportion to the 
applicant's circumstances, you should send a confidential 
notice to that effect to the Home Office. It is as impor- 
tant to protect the Company against speculative insur- 
ance as it is against diseased risks. 



MEDICAL EXAMINER'S REPORT. 

Pulse. This question has been placed first in the 
"Report" in order that the rate and character of the 
pulse may be observed while the applicant is still seated, 
and before it has been disturbed by the incidents of the 
physical examination. 

Measurements. The height, and the dimensions of 
the chest and abdomen should be carefully measured, 
and not estimated. The weight should be taken without 
coat or vest, and where for any reason it is necessary to 
estimate, the word "estimated" should be inserted 
along with the figures ; otherwise the Company assumes 
the weight to be exact. 

Gain or Loss of Weight. It is important to know 
whether the applicant has recently gained or lost weight 
and, especially in the case of loss, the cause should be 
carefully investigated. Loss of weight is frequently the 
first manifestation of Tubercular disease. 

14 



Build. A careful study of all the facts available on 
this subject has demonstrated the very great influence 
upon longevity of considerable departures from the 
normal height and weight. When, therefore, the appli- 
cant is markedly over- or under-weight, the heights and 
weights of other members of the family must be re- 
corded, so that the significance of the peculiarity may be 
properly estimated at this office. Failure to do this 
always involves additional correspondence. 



NEW-YORK LIFE STANDARD TABLE OF HEIGHTS 
AND WEIGHTS AT VARIOUS AGES. 

MEN. 



Height 


Age 20 


Age 30 


Age 40 


Age 55 


5- 


114 


121 


125 


128 


- 1 


117 


124 


129 


132 


- 2 


121 


128 


133 


136 


5- 3 


124 


132 


137 


140 


- 4 


128 


136 


141 


145 


- 5 


1S2 


140 


145 


149 


5- 6 


136 


144 


149 


153 


- 7 


140 


148 


154 


158 


- 8 


144 


153 


158 


163 


5- 9 


149 


157 


163 


167 


-10 


153 


162 


168 


172 


-11 


158 


167 


173 


177 


6- 


162 


172 


178 


183 


- 1 


167 


177 


183 


188 


- 2 


172 


182 


189 


194 


6- 3 


177 


188 


195 


200 



15 



WOMEN. 



Height 


Age 20 


Age 30 


Age 40 


Age 55 


4- 9 


100 


105 


110 


118 


-10 


103 


108 


113 


121 


-11 


106 


111 


117 


125 


5- 


109 


115 


120 


128 


- 1 


112 


118 


124 


132 


- 2 


116 


122 


128 


136 


5- 3 


119 


126 


132 


140 


- 4 


123 


129 


136 


145 


- 5 


126 


133 


140 


149 


5- 6 


130 


137 


144 


153 


- 7 


134 


141 


148 


158 


- 8 


138 


146 


153 


163 


5- 9 


143 


150 


157 


167 


-10 


147 


154 


162 


172 


-11 


151 


159 


167 


177 


6- 


156 


164 


172 


183 



Age. If the applicant appears older than the age 
given, the fact should be recorded, as it will influence 
considerably the valuation placed upon the life. 

Identification. The complexion, color of hair, color 
of eyes, and also any striking or distinguishing mark by 
which the applicant may be readily identified, should be 
recorded. Some physical peculiarity, scar or mark, the 
shape of the teeth or the nose, etc., are valuable for 
that purpose. 

Deformity or Maiming. In consequence of an in- 
creased liability to accident, a risk otherwise good is 
often considerably impaired by deformity or maiming. 

16 



Where the deformity has been produced by Tubercular 
disease, or infantile Paralysis, the risk is further im- 
paired, by reason of the constitutional tendency under- 
lying these conditions. Tubercular disease of the bone 
and infantile Paralysis are both significant quite out of 
proportion to the deformity present., 

General Appearance. Quite aside from the phys- 
ical examination of the organs of the body, is the 
question whether the applicant manifests in his general 
appearance at least the average degree of vitality. 
You should notice "whether he is erect or stooped, 
pale or florid, whether the skin is of a healthy appear- 
ance. The Examiner should draw very valuable con- 
clusions from this study of the general appearance of 
his subject. 

Race. We wish to know whether the applicant be- 
longs to the Caucasian or some other race, or is of 
mixed blood. It is well known that some races are 
much more resistant to disease than others, and also 
that mixed races possess by no means the resistance of 
either of the parent stocks. 

Brain or Nervous System. Besides any evidences 
of disease of the nervous system, you should be on your 
guard to detect any mannerisms or striking mental 
peculiarity. 

The Heart. 'This Company takes the position that 
persons with heart disease are proper subjects for life 
insurance. We endeavor to make a careful study of 
each case, and to place an equitable valuation upon 
each life. In no other part of the physical examina- 
tion is the skill of the Examiner put to a greater test. 
For the sake of greater accuracy we make use of a 
" heart blank," of which the subjoined is an illustration, 

17 




Indicate Location of Apex by X 

Indicate Direction of Transmission by .y" 

Indicate Area over which Murmur is Heard by Q 

Is the Murmur Systolic or Diastolic ? 

Indicate Point of Greatest Intensity by O 

Give Rate and Character of Pulse After Vigorous Exercise. 

on which we ask our examiners to record the results of 
their findings. Your judgment of the "prognosis in the 
cases which you examine, will strongly influence our 
valuation. 

Lungs, In cases of Asthma, chronic Bronchitis, 
Emphysema, cured Phthisis and the like, or, where the 
family or personal history of the applicant shows a 
Tubercular tendency, you should examine the lungs with 
special care. It is the desire of the Company to offer 

18 



> 



insurance to such lives, and the character of your exam- 
ination and report will contribute quite as much to that 
end as the statistical data on which the Company bases 
its present liberal treatment of sub-standard lives. 

Stomach and Abdominal Organs. Where there is 
a history of Colic, you should satisfy yourself whether 
it was Renal, Hepatic or Intestinal in character, and 
give the duration and severity of each attack. When a 
history of Appendicitis is given, palpate carefully in the 
region of the appendix for either induration or tenderness. 
We especially desire to know the number of attacks 
and date of each, their severity and duration. Where 
there is a Hernia, it is important to know whether it is 
reducible or irreducible and whether a suitable truss 
is worn. 

Skin, Middle Ear, Eyes. Any serious or suspicious 
skin affection should be described. Middle Ear disease 
is of importance, especially in view of the liability to 
Mastoid Abscess. The frequency of the attacks, their 
severity, the character of the discharge, are all of 
importance. Blindness and deafness impair a risk by 
reason of increased liability to accident. 

Genito-Urinary Organs. Urine. See that the speci- 
men is voided under circumstances that will leave no 
doubt in your mind that it is the urine of the applicant. 
Under no circumstances should a report be based upon 
a specimen the origin of which is in doubt. 

Microscopic Examination of the Urine is not 
required unless called for by the Home Office. 

Stricture. You should secure a detailed history in 
such cases, satisfy yourself as to the character and 
efficiency of the treatment. It is particularly important 
to ascertain whether the flow of urine is now free. 

19 



Intemperance. No question is of greater impor- 
tance, and few are more often overlooked or neglected 
by the Examiner than that of the use of alcoholic 
beverages. We -wish to know whether the applicant is 
an abstainer, a moderate or an immoderate user, a 
steady drinker, or whether often or only occasionally to 
excess. We know that such risks are insurable, but we 
cannot estimate their value correctly without careful, 
conscientious assistance from our Examiners. 

Review. It is often a matter of surprise to us that 
some of our best Examiners submit to the Company 
reports in which there are glaring omissions, or in which 
the facts are only partially recorded. This always 
causes delay and extended correspondence. 

After you have completed your report of a case, it 
is a good plan to endeavor to place yourself in the 
position of the Medical Department of the Company; 
to read the papers as if you had no other knowledge 
of the case than that contained in the records before 
you, and to ask yourself if you get from them the 
same idea of the risk that you obtained from the ex- 
amination itself. If you do, your report will prove 
satisfactory at the Home Office ; if not, it is incomplete. 

Incontestability. This Company now writes policies 
which are incontestable from the date of issue, and, as 
they are issued based upon your report, you will see at 
once how important it is that it should contain all the 
facts which have any bearing upon the value of the risk. 

Place of Examination. It is sometimes necessary 
that we should know just where the examination was 
made. You should, therefore, describe the place as 
follows : " at my office " ; " at his residence " ; "at his 
office " ; " at his farm, 3 miles south of " ; and so on. 

20 



Field of Operation. The Medical Examiner is ex- 
pected to act only in the community where he resides, 
and should not make examinations in the territory of 
another Examiner except when the latter is for any rea- 
son unavailable. In such event, he should add to his 
report a statement of the circumstances which seemed 
to him to warrant his irregular action. 

Appointment. This Company does not give formal 
commissions of appointment to its Examiners, and it 
reserves the right to make from time to time such 
changes in its staff of Examiners as seem for the best 
interests of the Company. 

Bills. To enable the Company to properly check 
and audit your accounts, the completed papers of each 
case are required at the Home Office. Bills are payable 
monthly at the Home Office, and blank forms on which 
to present them are supplied on request. 

Supplementary Report. Whenever, on account of 
your personal or business relations with the applicant 
or agent, you find it necessary to omit from the exami- 
nation papers any part of the medical history or the 
results of your examination, you are at liberty to for- 
ward all papers direct to the Home Office ; or, allowing 
the papers to go through the agent's or manager's hands, 
you may send to the Company a supplementary report 
mailed to the Home Office. . (See Special Notice, page 2.) 

In conclusion, what has already been said may be 
summarized as follows : 

1. This Company now insures under-average as well 
as selected lives. It offers insurance to practically all 
who apply. 

2. In each case it adjusts the plan of insurance to 
the insurance value of the risk. 

21 x 



3. The Medical Examiner's Report serves as a basis 
of valuation, and determines the plan upon which the 
insurance is offered. 

Therefore your report should present a pen-picture 
of the life so accurate and complete that the Medical 
Department at the Home Office, without seeing the risk, 
may place the correct valuation upon it, and may grant 
a policy fair and equitable to both the applicant and 
the Company. 

S. Oakley VanderPoel, M. D., 

Medical Director. 



22 



For the convenience of the Medical Examiners of 
the Company, we add the following in regard to the 

EXAMINATION OF URINE. 

As quickly as possible after it is passed, the specimen of urine 
should be examined with respect to each of the following points : 

1. Quantity in 24 hours. 4. Reaction. 

2. Color. 5. Transparency. 

3. Specific Gravity. 6. Albumen or Sugar. 

1. The Quantity of urine passed by an adult in good health is 
about 45 to 50 ounces in 24 hours ; but it is subject to variations 
within considerable limits, depending upon such conditions as the 
temperature and humidity of the atmosphere, the activity of the skin, 
the amount of the expiratory exhalations, and the amount of fluids or 
of liquid foods ingested. 

In Disease it varies from the enormous quantities passed in dia- 
betes, in hysterical polyuria and in the amyloid and the old granular 
kidney, to the scanty flow of the febrile state and of some forms of 
disease of the kidneys. 

2. The Color is usually a pale yellow or amber, though it varies 
with the quantity of urine voided. With a copious flow the color is 
very pale ; with a scanty flow it may be very dark. 

23 x 



In Disease it varies from the dark, smoky-brown of acute Bright's 
disease, through the high-colored urine of theTebrile state, and the 
pale straw color of diabetic urine, to the almost colorless urine of the 
hysterical state, and of some cases of contracted kidney. 

3. The Specific Gravity of urine may be stated at 1,020, under 
ordinary circumstances, although it may vary in health between 1,010 
and 1,025, dependent upon the same causes as those which influence 
the variation in quantity and in color. Since the amount of solids 
excreted by the kidneys is fairly constant, this variation in specific 
gravity is approximately in inverse ratio to the amount of urine voided. 

The Specific Gravity is best obtained by means of the Urin- 
OMETER. This instrument is usually graduated between 1,000 (the 
specific gravity of distilled water) and 1,060, and, when used, care 
should be taken that it is perfectly clean and that it does not cling to 
the side of the vessel in which the test is made. 

In Disease this range is increased. In diabetes it may be 1,040, 
1,050 or higher. In the earlier days of acute Bright's disease, and in 
the febrile state, it is high, and from that it ranges to that of the cir- 
rhotic and the amyloid kidney, of diabetes insipidus or of the hysteri- 
cal state, where the specific gravity may be 1,005 or ^ ess - Since, 
however, urine with specific gravity 1,010 has been found to contain 
sugar, and since the normal specific gravity has often been noticed in 
old cases of Bright's disease and in severe diabetes, the specific gravity 
cannot be relied on as an accurate guide to disease. But an average 
daily specific gravity of 1,025 or over is always suggestive of the 
presence of sugar, and of 1,015 or under, of chronic Bright's disease. 

4. The Reaction of normal urine is usually acid — due, probably, 
to acid phosphate of soda — but it may be neutral or alkaline. 

The reaction is determined by the use of litmus papers. The red 
becomes blue in the presence of an alkaline urine, and the blue paper 
becomes red if the urine is acid. When the reaction is not well 
marked, both the red and blue papers should be used. The acidity 
of urine is increased by an albuminous diet, and vegetable foods de- 
crease it or render the urine alkaline. 

In Disease the acidity is decreased in Anaemia and in some nervous 
affections, and is increased in diabetes and fevers. 

5. Transparency. The urine is naturally transparent, but, within 
the limits of health, it may be more or less opaque, on account of 



the presence of 



24 



A. Earthy Phosphates, C. Mucus, 

B. Mixed Urates, D. Bacteria. 

A. The Earthy Phosphates may cause normal urine, at the 
moment it is voided, to be opaque. Shortly afterwards they subside 
and form a bulky, fiocculent sediment, with clear urine above. They 
may be recognized by the fact that the application of heat will increase 
the opacity, while a few drops of Nitric or Acetic Acid will cause it 
to disappear. 

b. The Mixed Urates often render a cold urine turbid. They 
subside quite rapidly and form a white or pinkish deposit at the bottom 
and on the sides of the containing vessel, much more dense in char- 
acter than that of the phosphates. A gentle heat causes this opacity 
to disappear. 

c. Mucus from the genito-urinary tract may occur in sufficient 
quantity, within the limits of health, to cause some opacity in the 
urine. It forms a light, fiocculent sediment, much like that pro- 
duced by the phosphates, but which may be distinguished from the 
latter by the fact that alkalies, heat and strong acids have no effect 
upon it, while Acetic Acid increases the opacity by coagulating the 
mucin. 

D. Bacteria. When a specimen of urine is allowed to stand for 
some time, especially in hot weather, it becomes opaque on account of 
beginning decomposition and the development of Bacteria. This 
change is important because it interferes with the delicacy of the tests 
for Albumen ; and it is on this account that a specimen of urine should 
be examined while fresh. 

When, however, it becomes necessary to examine for Albumen a 
specimen of turbid urine, which is not rendered transparent by filtra- 
tion, it should be treated by the method suggested by Hofman & 
Ultzman, which is as follows : Add to a portion of the urine, in a 
clean test-tube, about one-quarter its volume of Liquor Potassae, boil 
the mixture and filter. Should this filtrate be not quite clear, add one 
or two drops of Magnesian Fluid,* warm again and filter. This fil- 
trate always appears clear and transparent. The presence of Albumen 
may then be detected by the Nitric Acid test. 



* The formula of the Magnesian Fluid is as follows : Magnesium Sulphate and 
Ammonium Chloride, of each one drachm ; Liquor Ammoniae, one drachm ; Distilled 
Water, one ounce. Mix. 

25 



In Disease, the urine may be opaque on account of the presence 
of— 

a. Pus. This forms a deposit which often resembles that of the 
urates. It is distinguished from it by the fact that heat increases the 
opacity of purulent urine, and from phosphatic deposit by the fact that 
it is not cleared up by the addition of a few drops of acid. 

b. Decomposition, as in old cases of cystitis^ in which the urine 
contains bacteria, pus, mucus, epithelium and, perhaps, shreds of dis- 
organized tissue. 

c. Fat, as in chylous urine. Fat is recognized by the well-known 
power of ether to dissolve it. 

6a. Albumen. The presence of Albumen in the urine is always 
suggestive of such grave pathological conditions that its recognition 
becomes one of the most important features in the examination of 
urine. Many tests have been brought forward for this purpose, and 
have had their earnest advocates, but those which have become most 
generally recognized for simplicity and effectiveness are the Nitric 
Acid test and the heat test. 

The Nitric Acid Test. Into a clean test-tube about half an inch 
of pure, colorless Nitric Acid is poured. The test-tube being then 
held at a considerable angle, a quantity of clear urine is allowed to 
flow from a pipette slowly down the inclined side of the tube, until an 
inch of urine overlies the acid. This must be carefully done, so that 
there shall be no mixture of the acid and the urine. The presence of 
Albumen is indicated by a sharp, white band or zone of coagulated 
Albumen in the urine AT the line of contact of the acid with the urine. 
In order to recognize this band, where the amount of Albumen is 
small, the tube should be held in a good light against a dark back- 
ground. Sometimes this zone of coagulated Albumen develops very 
slowly, and it is, therefore, always well to look at the specimen again 
15 minutes after the test is made, having placed it carefully aside for 
that purpose. 

Errors. A specimen of urine which contains a large amount of 
Urates may show a whitish zone above the line of contact. This is 
caused by the formation of Acid Urates, and is distinguished by the 
fact that the zone is not so sharply defined as that formed by Albu- 
men, but fades gradually into the clear urine ; also, because it disap- 
pears on the application of a gentle heat. 

The presence of resin, not unusual after the use of such drugs as 
Balsam of Copaiba, Turpentine, etc. , produces a whitish zone similar 

26 



to that produced by Albumen. The addition of a few drops of Alco- 
hol will redissolve the resin. 

The Heat Test for Albumen. A clean test-tube is filled about 
two-thirds full of urine. To the upper part of this urine, heat is ap- 
plied by means of a spirit-lamp. If, when the urine has boiled, any 
diminution of transparency is noticed, it is due to Albumen, Mucin or 
the Earthy Phosphates. Then add a few drops of Acetic Acid and 
boil for a few moments. If the cloud is due to Phosphates, it will 
disappear ; if caused by Albumen or Mucin, it will persist. Next add 
carefully to the top layer of the urine, one drop of Nitric Acid. If 
the cloud still persists, it is due to Albumen ; if it disappears, it is 
caused by Mucin. 

N.B. — The urine must be acid in reaction before boiling. If not, 
add one or two drops of Acetic Acid. 

Error. If the urine is slightly turbid from decomposition and the 
presence of Bacteria, any delicate change in its opacity cannot be seen, 
and it must be filtered before applying the heat. If, after filtration, it 
still remains turbid, it should be treated according to the suggestions 
already made under 5D, Bacteria. If the specimen is alkaline, 
Acetic Acid should be cautiously used, and if strongly acid, Liquor 
Potassae may be added, so as to render the urine only slightly acid. 

If Albumen is not found in a specimen of urine subjected to both 
of these tests, it may be safely affirmed that it is not present. 

6b. Sugar. Although many excellent authorities maintain that 
the presence of a small quantity of sugar in the urine may be entirely 
physiological, yet it is so often the first evidence of diabetes that 
its recognition is of the utmost importance in examinations for Life 
Insurance. 

Of the various tests which have been devised for that purpose, the 
Copper test — as in the form of Fehling's Solution* — and the Bismuth 



* Fehling's Solution is made after the following formula: 34.64 grams of c. p. 
Sulphate of Copper are dissolved in 200 grams of distilled water; 173 grams c. p. 
Neutral Tartrate of Soda are dissolved in 500 grams of Sodic Hydrate of a sp. gr. 
1. 12, and to this alkaline solution the copper solution is slowly added. The mixture 
is then diluted to one liter. The solution is made and sold by all the large drug 
houses. Perhaps the best preparation is that put up by Dr. E. R. Squibb, of Brook- 
lyn, N. Y., and the Medical Examiners of the Company are requested, whenever 
possible, to use this preparation. 

Whenever it is impossible to obtain a reliable preparation of Fehling's Solution, 



27 



test, deserve special mention. The composition of Fehling's Solution 
is based upon the fact, not only that sugar has the property of re-, 
ducing the Oxide of Copper to a lower state of oxidation, but also 
that a definite quantity of the former will react upon a known quantity 
of the latter (i c. c. of Fehling's Solution is reduced by .005 grams of 
sugar), and it is equally useful for qualitative and quantitative analysis. 

It is an alkaline fluid, of transparent, deep blue color, somewhat 
easily decomposed by exposure to the air and to light and warmth, 
therefore requiring, for its preservation, to be kept in small, closely- 
stoppered bottles, in a cool, dark place. 

The Test. A small quantity of the solution is poured into a clean 
test-tube, diluted with two or three times its volume of pure water, 
and boiled for a few seconds over a spirit-lamp. If the mixture 
becomes turbid, or a yellow or brick-red precipitate forms, it has prob- 
ably been kept too long or has been improperly prepared. If, 
however, the mixture retains its transparent, deep blue color, it may 
be relied upon, and the test is proceeded with. To the hot mixture the 
urine is added, drop by drop, and the heat is occasionally applied, 
until a volume of urine has been added equal to the volume of the 
mixture. If sugar is present in quantity, the first few drops will usu- 
ally cause a yellow opacity to appear, which spreads through the 
mixture, changing slowly to red as it settles to the bottom of the test- 
tube. A small quantity of sugar causes this reaction to take place 
more slowly. If no reaction takes place, the urine, clinically speak- 
ing, is free from sugar. 

Errors, a. The urine must be fresh. A small quantity of .sugar 
may fail to cause the reaction in an ammoniacal urine. 

b. Albumen interferes with the reaction and must be removed 
before the test is made. This may be done by heating the urine, 
previously rendered only faintly acid, and filtering it. Care must 
be taken not to boil the specimen too long. 

c. The changes produced by the earthy phosphates must not be 
confounded with the sugar reaction. The former produce a flocculent 
precipitation in the midst of a transparent, greenish amber fluid. 



a fairly good substitute for qualitative work may be made as follows : 1 drachm of 
Sulphate of Copper, 2 drachms of Neutral Tartrate of Potash, 3 ounces of Liquor 
Potassae. Mix. Keep this closely corked and in a cool, dark place. It is to be 
used as detailed above for Fehling's Solution. 



28 



The Bismuth Tests are based upon the fact that the action of 
sugar upon the Bismuth salts is the same as upon the Salts of Copper. 
They have advantage over the Copper tests of being less sensitive to 
the decomposing power of other organic compounds. 

The Test, which is ordinarily employed (Boettger's), is conducted 
as follows : the urine is mixed with an equal volume of Liquor Po- 
tassae or Sodae, a small quantity of Bismuth Subnitrate is added, and 
the mixture is boiled for a short time. If sugar is present, insoluble 
black Oxide of Bismuth is formed and deposited on the sides of the 
test-tube ; or if the quantity of sugar is small, the white Bismuth pow- 
der becomes tinged with gray. 

Errors. Only a very small quantity of Bismuth should be used, 
as an excess of Bismuth, if the amount of sugar is small, may conceal 
the reaction. 

If Albumen is present in the urine, a reaction, due to the forma- 
tion of the black Sulphide of Bismuth, may take place, which resembles 
that produced by sugar and may be mistaken for it ; the Albumen 
should, therefore, be removed from the urine before the test is made. 

Another Test for Sugar. Mix equal parts of urine and Fehling's 
Solution in a test-tube and let them stand in a moderately cool place 
for twelve hours. If there, is any orange-red deposit, sugar is present. 
This test is useful mainly as corroborative of others. 

To insure greater certainty in all doubtful cases, both the Bismuth 
and Copper tests should be employed. 

Microscopical Examination. The value of such examination of 
course depends upon the knowledge and skill of the microscopist, and 
as only those thoroughly familiar with such examinations will, natur- 
ally, be called upon to make them, there is no necessity for any 
instructions as to the paraphernalia or technique required. 



29 



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